CAPE PENINSULA

CAPE PENINSULA
UNIVERSITY OF TECHNOLOGY
Cape Town Campus Bellville Campus
P O Box 652 P O Box 1906
CAPE TOWN 8000 BELLVILLE 7535
Website:www.cput.ac.za
APPLICATION FOR ADMISSION: 2005
Dear Sir/Madam
We wish to thank you for showing an interest to study at the Cape
Peninsula University of Technology.
Enclosed please find the following documents.
APPLICATION FORM
Documentation to be submitted.
Certified copies of:
1. Matric certificate or equivalent qualification.
2. Your grade 11 (Final) results clearly marked HG/SG on the advice of results.
3. Certificate of good conduct (if you are transferring from another Higher Educational Institution).
4. Academic record (if you are transferring from another Higher Educational Institution).
5. Identity document/ Birth certificate(with ID number)COMPULSORY.
6. Application fee is R100, 00 (Postal order or cheque) and the closing date is 31 August 2004.
7. You may submit two career choices for this fee. Should you submit two career choices, please attach
duplicate certified copies of your documents.
8. International academic results to be evaluated by the South African Qualifications Authority
(SAQA), before submission. (Tel. +27 +12-4315000)
9. A separate questionnaire for RADIOGRAPHY COURSE (ONLY) must be completed, including
the application form.
Please ensure that you complete the APPLICATION form in FULL as per
INSTRUCTION on page 10 of the application form. ATTACH relevant documents and
enclose your application fee.
We look forward to receiving your application.
Yours faithfully
Admissions Officer
Please Note: No student will be allowed to register without an identity document or valid study
permit (international students)
DEPARTMENT OF HEALTH SCIENCES (Bellville Campus)
(Environmental Health, Nursing, Biomedical Technology &
Radiography)
Dear Applicant
APPLICATION FOR ENROLMENT: RADIOGRAPHY
(NATIONAL DIPLOMA AND B. TECH)
With reference to your application for radiography training, we require further
information in order for your application to be considered.
Please complete the radiography form enclosed, making sure that all sections are
answered fully. Return the completed application form to The Cape Peninsula
University of Technology (Bellville Campus) together with all the supporting
documents, as specified. These must be returned by
31 August.
Applicants for post-graduate studies will be notified whether their application was
successful and details regarding registration. All other applicants will be notified as
soon as possible whether or not they are on the short list of applications. All short
listed applicants will be invited for an interview before the final selection procedure is
completed.
There are many applicants for radiography and of the several hundred who apply
approximately 60 students will be selected. The majority of those accepted are for
Diagnostic Radiography. Approximately 6 students will be accepted for Therapeutic
Radiography, 8 for Ultrasound Radiography and 4 students for Nuclear Medicine
Radiography. These figures are the total number for The Cape Peninsula University of
Technology.
Yours faithfully
MR MS HASSAN
HEAD OF DEPARTMENT
HEALTH SCIENCES
CAPE PENINSULA UNIVERSITY OF TECHNOLOGY
HEALTH SCIENCES – RADIOGRAPHY
APPLICATION FORM
TO BE COMPLETED IN APPLICANTS OWN
HANDWRITING
1. PERSONAL (PLEASE USE BLOCK CAPITALS)
1.1 SURNAME : ______________________________________
1.2 SURNAME ON MATRIC CERTIFICATE : ______________________________________
1.3 FIRST NAME/S (in full) : ______________________________________
1.4 POSTAL ADDRESS : ______________________________________
______________________________________
_____________________________________
POSTAL CODE : ______________________________________
1.5 TELEPHONE NUMBER
Home : ______________________________________
Work : ______________________________________
1.6 DATE OF BIRTH : ______________________________________
1.7 SEX : ______________________________________
1.8 IDENTITY NUMBER : ______________________________________
1.9 NATIONALITY : ______________________________________
1.10 MARITAL STATUS : ______________________________________
1.11 HOME LANGUAGE : ______________________________________
1.12 CHILDREN
Number : ______________________________________
Ages : ______________________________________
2. ACADEMIC
2.1 SCHOOL LEAVING EXAMINATION: ____________________________________________
2.2 MONTH WRITTEN : ____________________________________________
2.3 YEAR WRITTEN : ____________________________________________
RESULTS: - If you have passed Grade 12 give these symbols.
- If you are in your final school year give your Grade 11 results and a copy of
your Grade 12 June report.
OTHER
SUBJECTS GRADE(H/S) SYMBOL GRADE (H/S) SYMBOL
SUBJECTS
ENGLISH
(1st/2nd language)
AFRIKAANS
(1st/2nd language)
MATHEMATICS
PHYSICAL SCIENCE
BIOLOGY
2.4 NAME OF SCHOOL : ______________________________________
2.5 ADDRESS OF SCHOOL : ______________________________________
______________________________________
______________________________________
POSTAL CODE : ______________________________________
2.6 TELEPHONE NO (School) : ______________________________________
2.7 CERTIFICATE : ______________________________________
(eg Cape Senior Certificate/Joint Matriculation Board)
2.8 POST-SCHOOL
COURSE : ________________________________________________________
YEAR : _______________________
COLLEGE/UNIVERSITY/TECHNIKON/OTHER: _________________________________
_________________________________
SUBJECTS WRITTEN RESULTS SUBJECTS WRITTEN RESULTS
If you did not complete a course, give reason/s:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Note: Additional information can be given on a separate page if space is not sufficient for
all courses done.
3. EMPLOYMENT (including casual work)
NAME OF EMPLOYER & REASON FOR
POSITION HELD FROM TO
TELEPHONE NUMBER LEAVING
Note: If space is not sufficient additional information can be given on a separate page.
4. HEALTH
4.1 Have you any disability? If so, describe:
___________________________________________________________________________
___________________________________________________________________________
4.2 Have you had any therapy? If so, explain:
___________________________________________________________________________
___________________________________________________________________________
4.3 Have you ever had any accidents? If so, describe:
___________________________________________________________________________
___________________________________________________________________________
4.4 Have you ever had any operation? If so, describe:
___________________________________________________________________________
___________________________________________________________________________
4.5 Have you ever suffered/do you suffer from problems of any of the following?
(Give dates and mention medical treatment)
• Eye : __________________________________________________
• Chest : __________________________________________________
• Heart : __________________________________________________
• Rheumatic fever : __________________________________________________
• Back : __________________________________________________
• Feet : __________________________________________________
• Headaches/Migraine : __________________________________________________
• Allergies : __________________________________________________
• Menstruation : __________________________________________________
• Other : __________________________________________________
4.6 Have you had more than 5 consecutive days off sick in the past 3 years?
YES NO
If yes, give brief details:
___________________________________________________________________________
___________________________________________________________________________
5. GENERAL
5.1 Have you ever been convicted of a criminal offence? If yes, give brief details:
___________________________________________________________________________
___________________________________________________________________________
5.2 Have you ever been dismissed from employment? If so, when and what for?
___________________________________________________________________________
___________________________________________________________________________
6. HOBBIES
Do you enjoy any hobbies? If so, please mention these:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. EXTRAMURAL ACTIVITIES/INTERESTS
Do you participate in any sport or social activities? If so, mention these:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. RADIOGRAPHY
8.1 The radiography course you are applying for is _____________________________________
8.2 How did you hear about this course? _____________________________________________
___________________________________________________________________________
8.3 Have you ever applied for a radiography course before?
YES NO
8.4 If so, where? ________________________________________________________________
And when? _________________________________________________________________
8.5 Have you applied at any other education institution/s this year?
YES NO
8.6 If yes, list the course/s and institutions:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8.7 What is your first choice? ______________________________________________________
8.8 Describe any experience you have had with sick and/or injured people?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8.9 What is your opinion of working in a profession which requires you to work over weekends,
night-duty and on call?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
9. RADIOGRAPHY COURSE
9.1 Please write a paragraph explaining what you know about radiography and the course. Also give
reasons for selecting this career and this Technikon.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________
I declare that the information given is, to the best of my knowledge, correct. If admitted to the
course, I undertake to abide by the rules of the hospital and technikon.
SIGNATURE OF THE APPLICANT : ____________________________________
DATE : ____________________________________
Please complete this application form as soon as possible, and return by 31 July in order to
be considered for selection.
INDICATE THE HOSPITAL YOU WOULD LIKE TO TRAIN AT BY
TICKING THE APPROPRIATE BLOCK
GROOTE SCHUUR HOSPITAL
(Predominantly English)
TYGERBERG HOSPITAL
(Predominantly Afrikaans)
BY MEANS OF A (√) INDICATE WHAT YOU ARE APPLYING FOR:
• DIAGNOSTIC RADIOGRAPHY
• NUCLEAR MEDICINE RADIOGRAPHY
• THERAPEUTIC RADIOGRAPHY
• ULTRASOUND RADIOGRAPHY
(If you are applying for more than one, please indicate priority 1st, 2nd, 3rd)
HIGHER STUDIES ARE CONDUCTED MAINLY IN ENGLISH
FULL-TIME PARTTIME
B TECH
Indicate Discipline
M TECH
Indicate Discipline
The following must be included with this application:
1. Certified copy of Identity Document
2. Two recent references
3. The name and contact number/address of two referees
4. Certified copy of Grade 11 School Report
5. Certified copy of Grade 12 June School Report
(September report to be forwarded as soon as possible)
6. Certified copy of Senior Certificate if you have matriculated
7. Documents/certificates of post-school study if applicable
8. Employees references/reports if applicable
YOU WILL BE NOTIFIED IN DUE COURSE WHETHER YOUR APPLICATION IS
UNSUCCESSFUL
OR
WHETHER YOU ARE ON THE LIST OF APPLICANTS FOR INTERVIEW
If you are invited to the interview please bring the following with you:
1. Two passport size photographs
2. Your most recent school report